SUMARIO

Alergol Inmunol Clin 2000;15:275-277

M.a D. Guimaraes Editorial

Occupational Dermatology
Service. National Institute
of Occupational. Medicine
and Safety. Madrid. Tattoos, yesterday and today

L
attoos are performed by the exogenous insertion of pigments in-
to the skin, thus creating insoluble pigment deposits in the der-
mis. The term "tattoo" is derived from the Polynesian "TA",
which means "to draw".
Tattooing is a very ancient custom. Among the primitive peoples,
tattooing was used for embellishment, while in other cultures it constitu-
ted a sign of distinction or of social rank. Tattoos were considered as ta-
lismans by some tribes, and in ancient Egypt they had a healing signifi-
cance. In New Guinea, the Hita tribes applied tattoos from early
childhood onwards, the designs being gradually enlarged up to marriagea-
ble age, while in the Cayman Islands only married women were tattooed.
From the XV Century onwards this practice became popular and wides-
pread among sailors, soldiers, and adventurers and, sometimes, among
people leading unsettled lives and in marginal social classes. However, in
the XIX Century tattooing became fashionable among the jeunesse dorée
in Europe and America, and achieved its greatest splendour with well-
known persons from the nobility or the Royal families bearing large tattoos
(such as King George V of England, Czar Nicholas II of Russia, King
Oscar of Sweden, Kaiser Wilhelm II of Germany, and a long et caetera).
In our times, tattoos have again become an increasingly extended
fashion which may give rise to medical problems, both because of the
procedure used for their creation, as it implies invasive techniques with
many undesirable side effects despite stringent hygienic conditions and
because of the eventual later desire to eliminate pre-existent tattoos.
The tattooing procedures have been quite variable, depending on
the epoch and the cultures involved. The most primitive tattoos, in Afri-
ca and Oceania, were performed by creating a number of deep wounds
in the skin which, upon scarring, left a pattern of marks forming the de-
sired figure or shape. Means for delaying wound healing were even
used sometimes, with the purpose of achieving hypertrophic scars. This
scarification technique has again become fashionable, a development
which is indeed difficult to understand and particularly so if the people
concerned were aware of the risk of development of true keloids.
In Greenland, the Eskimo peoples threaded needles with pigment-
impregnated threads under the skin; when the threads were later remo-
ved, they left behind fine coloured lines that were permanent.
Another tattoo technique appeared with the discovery of gunpow-
der: this technique comprised "pricking" a drawing or pattern with
needles impregnated or covered with gunpowder. The pricked pattern
was then fired and left behind, after the healing of the small punctate
burns, a dark blue pointillé design.

275
M.a D. Guimaraes
The custom of tattooing presently includes the
application of cosmetic tattoos, as permanent make-
up, in selected areas of the body such as the eyelids,
the lips, etc.
Generally speaking, when talking about tattoos
we usually mean those that have been applied volun-
tarily and in a more or less artistic pattern. However,
and in the medical context, there are also tattoos in
the form of permanently stained skin because of the
penetration of particulate matter of varying nature.
An example of such tattoos are the stains caused by
gunpowder explosions, either upon the impact of fi-
reworks on the skin or in the context of some profes-
sions such as mining or metallurgy, in the latter case
because of the penetration of particulate matter in
the course of the habitual occupational activities.
Tattoos are also not infrequent as a sequel of moto-
ring accidents, because of the penetration of sand
and other particulate matter adhering to abraded areas
of the skin. Tattoos have also been used in Medicine
with an aim to restore or repair pigmentation defects.
The first known reference in this context dates back
to 1859 and related to a corneal tattoo imitating the
pupilla. These methods were generally abandoned in
the course of time, as they did not easily achieve the
desired results.
In another context, tattoos have been a theme
for study by anthropologists, sociologists and ethno-
logists in an attempt to clarify their meaning and the
reasons for performing them. In Spain, the Dermato-
logy Department of the University of Salamanca first
tried to assess the reasons for tattooing in 51 patients
with a total of 178 tattoos1. The response rate was
33.4%, and in all the responders there was a coinci-
dence of a number of circumstances, such as undesi-
red socio-familial environments, jail sentences, toxic
substance addiction, or the obligatory military servi-
ce. Some authors consider that tattoos are sometimes
the consequence of an identity crisis during the ado-
lescence stage.
The current expansion of the tattooing fashion
entails a considerable number of dermatologic pro-
blems. A correct tattooing technique should use
substances that are non-toxic, non-irritant and non-
absorbable, yet even with these precautions risks
persist, and there have been reports of granuloma-
tous and hypersensitivity reactions to the pigments
and also of lichenoid reactions, mainly in relation to
276
red staining pigments. In the past, the red colour was
achieved with mercury compounds, while at present
iron oxides and organic pigments derived from san-
dalwood and red lacquer are used. Occasional liche-
noid, granulomatous, sarcoidosis-like, pseudolymp-
homa and benign lymphoadenosis reactions occur,
without an underlying immunologic mechanism. The
skin tests performed with the pigment or pigments
involved are negative, and the histologic changes, in
the lichenoid cases, are those of an inflammatory
non-eczematous reaction with an infiltrate in the der-
mis that erodes the basal stratum and which is undis-
tinguishable from the image of lichen planus. The
pigments remain embedded in the dermis and some-
times behave as foreign bodies, giving rise to the
formation of granulomata, which progressively affect
the whole area of the tattoo.
Reactions induced by black pigments are infre-
quent; however, two cases of allergic dermatitis have
been recently reported, one of them induced by an
India ink tattoo in which the sensitising agent could
not be identified, and the other one induced by an al-
so unidentified black pigment.
In recent years it has become rather frequent to
see temporary "tattoos" performed with Henna. This
pigment is used for painting the desired design on
the skin without any form of puncture, prick or sca-
rification, and the painted pattern lasts for some
weeks. The present issue publishes an interesting re-
port of a case of contact dermatitis induced by such
a Henna tattoo, caused by the presence of para-
phenylenediamine (P.P.D.A.) in the pigment prepara-
tion used. This observation should be kept very
much in mind, as sensitisation to this pigment th-
rough hair dyes is not at all infrequent, particularly
in Spanish women. This technique, which might at
first appear to be harmless, is not devoid of risk,
both in previously sensitised persons and because of
the possibility of inducing sensitisation to P.P.D.A.
derivatives. The presence of such derivatives has be-
en demonstrated in Henna powder of various origins,
and I therefore consider that this form of "tattooing"
should be discouraged, particularly in persons with a
history of atopy.
While the assistance to and resolution of unde-
sired adverse reactions caused by tattoos already re-
presents a considerable medical problem, a further
frequent problem arises from the already mentioned
SUMARIO
requests for tattoo removal. In some cases, the ca-
rriers of tattoos were naïvely confident that it would
gradually vanish; this does not happen, or is not
achieved correctly and with good cosmetic results.
Therapy with the pulsed dye laser has represented an
important advance in the elimination of tattoos, as it
is based on selective thermolysis with minimal in-
volvement of the skin and without scarring. The ale-
xandrite PLTL (Pigmented Lesions Tattoo Laser)
destroys the pigment through a photoacoustic mecha-
nism, fragmenting it into microparticles that may be
phagocytosed by the macrophages and thus achie-
ving a gradual clearing of the tattoo. With the PLDL
(Pigmented Lesions Dye Laser) the treated areas ac-
quire an ashy-purplish discoloration that remits after
two weeks with clearing of the tattoo pigmentation.
It is recommended that the interval between therapy
sessions be one month so as to give sufficient time
for the macrophages to eliminate the micronised pig-
ment. Depending on the size, depth and colour of the
tattoo, between eight and ten sessions are required.
However, the results have not always been satis-
fying, and the procedure is furthermore lengthy and
costly.
Editorial
A large number of products have the ability to
sensitise through contact or local application to the
skin; however, they can be removed, as they are not
embedded in the skin.
Tattoos? No, thank you!
REFERENCES
1. Carvallo del Rey AF, Fernández G, Armijo M. Aspectos clínicos y
terapéuticos de los tatuajes. Actas Dermo-Sif 1990; 81: 479-484.
2. Lucker GPH, Koopman RJJ, Van der Valk PGM. Millstone tattoo:
a regional trade-related dermatosis. Contact Dermatitis 1993; 29:
217-218.
3. Vázquez García J, Seoane Lestón J, Cazenave Jiménez A. Tatuaje
ritual en mucosa oral. Actas Dermos-Sif. 1994; 85: 445-446.
4. Tresukosol P, Ophaswongse S, Kullavanijaya P. Cutaneous reaction
to cosmetic lip tattooing. Contact Dermatitis 1997; 36: 176.
5. Treudler R, Tebbe B, Krengel S, Orfanos CE. Allergic contact der-
matitis from black tattoo. Contact Dermatitis 1997; 37: 295.
6. Gallo R, Parodi A, Cozzani E, Guarrera M. Allergic reaction to In-
dia ink in a black tattoo. Contact Dermatitis 1998; 38: 346-347.
7. Gallo R, Ghigliotti G, Cozzani E, Balestrero S. Contact Dermatitis-
from para-phenylenediamine used as a skin paint: a further case.
Contact Dermatitis 1999; 40: 57.
8. Rubegni P, Fimiani M, De Aloa G, Andreassi L. Lichenoid reaction
to temporary tattoo. Contact Dermatitis 2000; 42: 117-118.
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